Common Examples of Fraud_CPMA Exam

🚨 Common Examples of CMS-Related Fraud

• Billing for Services Not Provided

  • Submitting claims for medical procedures, tests, or equipment that were never actually delivered to the patient.

  • Example: A clinic bills Medicare for diagnostic tests that were never performed.

• Upcoding

  • Charging for a higher-level service than what was actually provided.

  • Example: Billing a routine check-up as a complex consultation to receive higher reimbursement.

• Unbundling

  • Separating services that should be billed together to increase payment.

  • Example: A lab bills each blood test individually instead of as a bundled panel.

• Kickbacks and Referral Schemes

  • Offering or receiving payment for patient referrals or services.

  • Example: A physician receives money from a medical imaging center for sending patients there.

• Durable Medical Equipment (DME) Fraud

  • Billing for equipment that was never delivered or not medically necessary.

  • Example: A supplier bills Medicare for motorized scooters but delivers manual wheelchairs.

• Medical Identity Theft

  • Using stolen patient or provider information to submit false claims.

  • Example: Fraudsters use a beneficiary’s Medicare number to bill for services they never received.

• Phantom Clinics

  • Fake medical offices that exist only on paper to submit fraudulent claims.

  • Example: A XXX company bills Medicare for $500,000 in equipment for non-existent patients.

• Prescription Drug Resale Schemes

  • Recycling and reselling medications paid for by Medicare.

  • Example: Fraudsters recruit patients to get prescriptions, then resell the drugs multiple times.

🧾 Real Case Snapshot

One convicted fraudster admitted to laundering millions through a fake medical supply company. Agents found $2.5 million in cash hidden in PVC pipes under his home. He billed Medicare for orthotic braces and wheelchairs for patients who didn’t exist.

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